Onset of coeliac disease during treatment with interferon for chronic hepatitis C

The immunomodulatory properties of interferon may concur to precipitate or worsen an underlying autoimmune disorders. We report the cases of two men who displayed the various features of coeliac disease during a treatment with 4-interferon (in one case associated with ribavirin) for chronic hepatitis C. The patients stopped the interferon treatment and the symptoms and histological disorders improved after a gluten-free diet. Alpha-interferon is available worldwide for treatment of chronic viral hepatitis. Before treatment with this drug, the patients would have to be monitored for coeliac disease.

A small peptide from durum wheat gliadin prevents cell agglutination induced by prolamin-peptides toxic in coeliac disease

A peptide (m.w. 1157.5 Da) able to prevent the agglutination of K562(S) cells induced by the peptic-tryptic prolamine digests of the cereals toxic in coeliac disease (i.e. bread wheat, rye, barley and oat) was characterized as one of the components of the peptic-tryptic digest of durum wheat gliadin. This peptide was synthesized in a high degree of purity with the solid phase method with the Applied Biosystem 431A. An amino acid sequence was identified in the 1157.5 Da peptide as being related to the largest common sequences previously detected in a series of bread wheat toxic peptides by other authors.

Study of behavior of rats with gluten-induced enteropathy

Association of different psychological and neurological disturbances with gluten intake in coeliac patients was repeatedly described. In the present study gluten-induced enteropathy was elicited in rats by prolonged intragastric administration of gliadin from birth to 10 weeks. Various neurological (contact and visual placing reactions, equilibrium on horizontal bar) and behavioral tests (open field and Morris water maze task) were used to assess the possible deficits. No substantial differences were found in the behavior of rats fed with gliadin compared with those fed with bovine serum albumin (control group). The only difference found between control and experimental rats was that gliadin-fed rats showed slightly higher emotionality in the open field test. It is concluded that prolonged application of gliadin to young rats at enteropathy-inducing dosages does not modify their behavior.

Non-coeliac sprue possibly related to methotrexate in a rheumatoid arthritis patient

We describe a case of non-coeliac sprue in a low-dose methotrexate treated patient suffering from rheumatoid arthritis. This is the first case report of this possibly reversible complication of methotrexate therapy. The diagnosis was confirmed by a duodenal mucosal biopsy revealing the characteristic intestinal histopathology of coeliac sprue. After discontinuation of the drug a repeat biopsy was almost normal, and completely normal after reintroduction of a normal diet. One could speculate about the methotrexate related mechanism of the villous atrophy: it might be either a direct toxic effect or a secondary effect of the immunosuppression.

Gamma-type gliadins cause secretion of prostaglandin E2 in patients with coeliac disease

Coeliac disease is induced by polypeptides in the prolamin fraction of wheat, termed gliadin. It has previously been demonstrated that the alpha-, the beta- and the gamma-gliadin fractions contain toxic components and it has furthermore been strongly indicated that alpha-type gliadins are toxic. Due to insufficient protein separation methods there has been no information as to whether also the gamma-type gliadins are injurious in coeliac disease. We have therefore purified one alpha-type (alpha-39) and two gamma-type gliadins (gamma-36 and gamma-47) in a preparative scale by a combination of different ion exchange chromatographies. The purity was analyzed by high performance liquid chromatography and by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulphate, while the typing was based on determination of N-terminal amino acid sequence. Six patients with coeliac disease in remission were included in the study. Each of the purified gliadins was given by an intestinal perfusion technique to two patients. The perfusion fluid was collected and analyzed for the concentration of prostaglandin E2 (PGE2) as a marker for a toxic effect. All patients reacted with increased PGE2 secretion. For the first time it is clearly demonstrated that gamma-type gliadins are active in coeliac disease.

Octreotide decreases biliary and pancreatic exocrine function, and induces steatorrhea in healthy subjects

A somatostatin analogue (SMS-201-995, hereinafter "octreotide") was s.c. administered to 5 healthy subjects under consecutive dripping of CCK-PZ (cholecystokinin-pancreozymin) and secretin (0.01 CHR U/kg/minutes), after inserting a Dreiling double tube into Treitz's ligament. Bile acid concentration, and bicarbonate and lipase excretions in duodenal juice were determined every 10 minutes up to 120 minutes and compared with controls. Moreover, octreotide (100 micrograms) was s.c. administered to 5 healthy subjects 30 minutes before meals for 7 days. Fecal fat and bile acid excretions before and after administration were determined. Bile acid concentration, and bicarbonate and lipase excretions in the octreotide group decreased to 1/3-1/4 that of controls. Bile acid concentration became 0 mM for 60 minutes. Fecal fat excretion increased; obvious steatorrhea occurred in 2 cases. Fecal bile acid excretion decreased to about 1/4. These results suggest that decreases in bile acid secretion should be considered, as well as pancreatic lipase and bicarbonate secretions, when fatty stool occurs after octreotide administration.

Characterization of the gliadin-derived peptides which are biologically active in coeliac disease

Reversed-phase HPLC on C18 silica gel at pH 3.5 was used to separate peptides in fraction 9, a mixture of peptides of unknown composition obtained from an enzymic digest of wheat gliadin. This fraction, which has been shown to be toxic to individuals with coeliac disease, yielded a principal peak as well as many minor peaks after HPLC. The significant peaks were subjected to amino acid analysis. The principal peak obtained was purified by rechromatography at pH 6.0 and shown to contain a dodecapeptide of sequence H-Arg-Pro-Gln-Gln-Pro-Tyr-Pro-Gln-Pro-Gln-Pro-Gln-OH. This peptide may have been derived from regions in the A-gliadin molecule corresponding to amino acids numbered 75-86 or from homologous regions in other gliadin molecules. Preliminary results indicate that it is active in two in vitro models of coeliac disease and that it could be the source of one of the undigested peptides (Hexapeptide II, (Glx)3, (Pro)2, Tyr) obtained from coeliac mucosal digestion of fraction 9. Some active serine-containing peptides were also obtained from chromatography at pH 3.5 and attempts are being made to correlate these with the other undigested peptide (Hexapeptide I) of composition (Glx)3, (Pro)2, Ser, obtained after coeliac mucosal digestion of fraction 9.

Chemistry, coeliac-toxicity and detection of gluten and related prolamins in foods

Some recent advances in the understanding of the chemistry of gluten proteins and its relationship to the toxicity of different fractions in coeliac disease (gluten intolerance) is reviewed. Most recent studies on gluten toxicity have used in vitro analyses of cellular immune activation by gluten fractions and peptides. Our work indicates that gliadin is the most active of the different protein families found within the wheat grain and that a specific peptide sequence located in the amino terminus domain of alpha-gliadin and containing the sequence proline-serine-glutamine-glutamine was most active. Improvement in the dietary management of coeliac disease is possible by use of test kits for the detection of gluten in foods. Both laboratory kits and home test kits (suitable for use by individual coeliacs) are available and reliably detect gluten from wheat, rye and barley even after cooking or baking.

Determination of the gluten content of foods

Coeliac disease affects 1:1,500 people in Europe. Treatment of the condition involves a gluten-free diet with avoidance of foods containing wheat, rye, barley or oats. Evidence suggests that individuals should adhere strictly to the diet as this reduces the increased incidence of malignancy observed in the condition. A large number of gluten-free products are currently available. Immunological assays have been developed to assess their suitability for patients with coeliac disease. Quantitative assays, based on both polyclonal antisera and monoclonal antibodies, methods of extraction and problems associated with interfering substances are reviewed in this paper.

[Non-tropical sprue and chronic inflammatory rectal stenosis in a patient with abuse of ergotamine-containing suppositories]

A 51 year old Yugoslavian patient was admitted to our hospital in reduced general condition with distinct hypocalcemia, osteomalacia, and with rectum stenosis. Our investigations led to the diagnosis of a malabsorption syndrome due to non-tropical sprue. The most likely cause of the rectum stenosis is an abuse of ergotamine-containing suppositories for several years. A gluten-free diet and the interruption of the use of the suppositories improved her general condition remarkably.

In vivo induction of gliadin-mediated enterocyte damage in rats by the mannosidase inhibitor, swainsonine: a possible animal model for celiac disease

Simultaneous feeding of gliadin and swainsonine, an inhibitor of alpha-D-mannosidases, in rats disturbed enterocytic maturation as shown by a marked loss of activities of alkaline phosphatase and gamma-glutamyltransferase. Morphologically, simultaneous treatment with gliadin and swainsonine caused destruction and decreased density of microvilli, as shown by electron microscopy. Neither gliadin nor swainsonine when given alone had significant effects on enterocytic enzyme activities or enterocytic morphology. Binding of enterocytic glycoproteins to both gliadin-Sepharose and concanavalin A-Sepharose was significantly increased in rats treated with swainsonine. Because swainsonine causes the formation of hybrid-type oligosaccharides with a high binding affinity to mannose-specific lectins, the observed alterations of enterocytic maturation and morphology are presumably caused by the increased binding of gliadin to enterocytic glycoproteins. A possible analogy in the etiology of celiac disease is discussed.

Steatorrhea associated with meclofenamate sodium therapy

Fenamates are a class of nonsteroidal anti-inflammatory drugs that frequently have gastrointestinal side effects. Diarrhea is seen fairly commonly. Malabsorption has been reported only 3 times with mefenamic acid, one of the family of fenamates. A case of steatorrhea due to meclofenamate sodium is presented here. Fenamates block net fluid absorption and also lead to histological abnormalities of the small intestine. The cause of the malabsorption seen in fenamate therapy is not known.

Mefenamic acid enteropathy

The clinical, radiological, and histological features of two patients with severe intestinal damage induced by mefenamic acid and mimicking coeliac disease are described. Symptoms rapidly reverted on withdrawal of the drug, and in one case, did not relapse during treatment with other non-steroidal anti-inflammatory drugs.

Treatment of metastatic islet cell carcinoma with a somatostatin analogue (SMS 201-995)

We used an octapeptide analogue of somatostatin, SMS 201-995, in dosages ranging from 150 to 450 micrograms/d administered subcutaneously in three daily doses for 1 to 16 months, to treat 22 patients with advanced malignant islet cell carcinomas. Of the 22 patients, there were 9 with gastrinomas; 3 with glucagonomas; 4 with insulinomas; 1 with ectopic production of parathyroid hormone; and 3 with mixed syndromes. The only biochemical marker in 1 patient was pancreatic polypeptide, and 1 patient had no demonstrable peptide production from the tumor. In 14 patients, dramatic decreases in the levels of circulating peptides (insulin, vasoactive intestinal polypeptide, gastrin, and glucagon) have been accompanied by major alleviations of symptoms. Steatorrhea appears to be the most significant toxicity. This analogue of somatostatin may be appropriate for use as early therapy in patients who have symptoms from syndromes related to islet cell carcinomas but in whom there is no immediate threat from tumor progression.

Comparison of four pancreatic extracts in cystic fibrosis

Four different pancreatin products, Pancrease, Creon, Pancrex V Forte, and Pancreatin Merck, were compared in a random crossover trial in children with cystic fibrosis. The results of our study showed that patients who received Creon and Pancrease had fewer gastrointestinal symptoms than patients who received Pancrex V Forte and Pancreatin Merck. Fat absorption was significantly improved with Pancrease when compared with Pancrex V forte and Pancreatin Merck. Also the fat absorption with Creon was superior to that with Pancrex V Forte. There was no significant difference in fat absorption between Pancrease and Creon. Pancrex V Forte and Pancreatin Merck, or Pancreatin Merck and Creon. Faecal nitrogen content was less with both Creon and Pancrease compared with Pancreatin Merck. Creon and Pancrease allow the patient with cystic fibrosis to take a high energy diet without any dietary restrictions.

Reappraisal of the 'lectin hypothesis' in the aetiopathogenesis of coeliac disease

The agglutinating properties of a crude gluten digest, purified gliadin fractions and established plant lectins were investigated using mammalian erythrocytes, rat enterocytes and normal and coeliac human enterocytes as the target systems. Gliadin preparations failed to cause agglutination of any of the cells tested, whereas established pure plant lectins were active cell agglutinins. These studies indicate that gliadin peptides do not interact with intestinal cells in a polyvalent, lectin-like manner and as such cannot be regarded as true lectins. Mucosal damage in coeliac disease is unlikely therefore to be related to lectin-like activity of gliadin.